Err On the Side of Treatment

New anti-opioid campaigns have some EPs afraid to treat pain adequately. But we need to use our clinical judgment, and when in doubt, err on the side of treating, rather than withholding.

For at least the last two to three years one of the biggest stories in medicine and the lay press has been the substantial increase in opioid-related deaths. The stats on the number of deaths and the rapid rate of increase are alarming. As a result there have been a number of high-profile initiatives to address the problem. The bottom line – clinicians are being strongly advised to use opioids less frequently and for shorter periods of time.

How do these initiatives affect the emergency department? Some cities have mandated (or at least advised) the limitation on the prescription of opioids from the ED for only a few days (typically three). To some of us, these guidelines and mandates were welcomed. Specifically, it gave us some tools to use when addressing patients with chronic pain – typically pain that cannot be objectively measured or observed – recurring headaches and back pain in particular. In fact, some EDs were posting signs in the waiting room indicating that opioids would not be prescribed under certain (most) circumstances. Fortunately CMS said the signs might be discouraging patients from obtaining a medical screening exam and therefore may be a violation of EMTALA. The signs came down.

The fact is that emergency clinicians deal with two kinds of pain. There is the pain that is clinically apparent and cannot be faked – the broken ankle, the periapical abscess, the laceration, the corneal abrasion, the cracked rib, the acute low back injury from a fall. All of these patients have acute pain that is likely to last a number of days and in these cases acetaminophen or ibuprofen just will not cut it. What are our choices? We may need to go to the opioids. We have nothing in the middle. Emergency clinicians need to be given the freedom to, in their professional judgment, prescribe short-acting opioids in the strength and duration that they see fit. No three-day limit, no avoiding needed opioids.

The second kind of pain is much more difficult to address, but it represents the minority of patients who will be discharged from the ED with pain – the patients with a genuine exacerbation or recurrence of pain (migraine, chronic back pain) and, even more uncommon, the patient seeking opioids as a result of addiction or who wants to sell them on the street (oxycodone can easily bring $12-$40 a tablet). Patients with pain that can be easily faked require that we make a judgment call – is the pain real or not.

Now here is where we can get into trouble: thinking that patients with real pain are faking or are symptom magnifiers. But it would be much better to make a mistake and give opioids to an addict or diverter than to not give them to a person who genuinely needs them – much better. We need to err on the side of treating rather than withholding. Some emergency clinicians have become jaded, based on their experiences, and pretty much refuse to prescribe opioids in the setting of chronic pain exacerbations. And all of the new regulations and guidelines just reinforce their prejudice.

Most states are in the process of developing PDMP’s – prescription drug monitoring programs – that allow clinicians to log in and view a patient’s controlled substance history. Too many different prescribers, too many different clinics and EDs, and the patient may be diverting. However, when a patient is determined to visit multiple clinicians and get pain meds it doesn’t necessarily mean that the patient is feigning pain and diverting. Maybe they have no access to routine care, maybe they have no access to pain management clinics, maybe they have no money and the ED is the only place that will see them. Maybe they are pretty desperate to get relief. They are not all criminals.

And yes, the patients I just described are truly difficult to manage given most of us can’t make a prompt referral to a facility that can provide a multidisciplinary, long-term approach to their problem. What are we to do? It is easy to be hard-asses and say “they won’t let me prescribe Vicodin any more” and hide behind a supposed guideline or regulation. Seems it would be the hospital’s responsibility to come up with some resources to address the care of these patients since we can’t effectively manage them in the ED. They need chronic care. And yes, we can prescribe a bridging dose of opioids, but if the patient can’t get prompt follow-up they will likely to show up in another ED soon.

Who are the real culprits? The Los Angeles Times, in its January, 2, 2016, reported the first conviction of a physician in the U.S. for murder as the result of her opioid prescribing behavior. She received a sentence of 30 years to life after being convicted in the overdose deaths of three of her “patients” – their ages were 21, 25 and 28. The doctor’s clinic made over $5 million in three years. The report quoted several doctors expressing concern that the conviction would jeopardize the care of patients who truly need adequate pain management by frightening clinicians (inappropriately).

Just scan the internet and you will find story after story regarding the illegal prescribing of controlled substances. One other recent Los Angeles Times story detailed a physician who prescribed over 10,000 controlled prescription drugs over 15 months while charging as much as $500 per prescription.

Tugg Valley Pharmacy is another similar case – but this time with a twist. Twenty nine controlled substance-addicted “patients” of a West Virginia clinic sued Tugg Valley Pharmacy and three others for filling the prescriptions of doctors operating a pill mill clinic. In a 3-2 decision the West Virginia Supreme Court said the plaintiffs could sue the pharmacies and four physicians for contributing to their drug addiction, even if the addiction had resulted in the committing of crimes to support their habits and pre-existed a relationship with the physicians. And, again, it was demonstrated that tens of thousands of prescriptions for controlled substances were written by the four doctors (one was the largest such prescriber in the state).

If you scan the internet there are numerous cases of physicians who have gone to the dark side and have become, in essence, drug dealers. But isn’t anybody watching? Wouldn’t pharmacies in rural West Virginia where the Tugg Valley case originated have noted the huge number of prescriptions coming through for controlled drugs? Clearly it would appear they have some substantial blame in this situation. And, in fact, it has gone even further. The Attorney General in West Virginia is now going after McKesson, the national distributor of the drugs dispensed at Tugg Valley – surely they would have noted something amiss as well.

It would be one thing if we had our act together with regard to the effective management of pain in the ED – but we don’t. Studies continue to document oligoanalgesic in children, women, the elderly and racial minorities. Seems the only group that may be getting adequate ED pain management is white males. And remember, a significant percentage of ED patients are presenting with acute or chronic pain.

What has not been studied very well is the outpatient prescribing of opioids from the ED. The following study looked at prescribing of opioids but doesn’t begin to address whether patients were undertreated on discharge – the message seems to be “we are not over prescribing” – exactly what I’m trying to convey in this essay. But are we underprescribing?

OPIOID PRESCRIBING IN A CROSS SECTION OF US EMERGENCY DEPARTMENTSHoppe, J.A., et al, Ann Emerg Med 66(3):253, September 2015 BACKGROUND: Pain is a factor in nearly two- thirds of ED visits, but the contribution of legitimate prescriptions to the growing opioid abuse problem is unknown. METHODS: This multicenter, retrospective cohort study, coordinated at the University of Colorado, described the circumstances of opioid prescribing in a national sample that included 3,284 consecutive adults (mean age 41, 52% female) presenting to 19 EDs over a one-week period (October 2012) who received an opioid (excluding tramadol) for a painful condition (not including cough suppression). Study outcomes were the numbers and types of prescriptions, characteristics of patients who received opioids, and indications for pain relievers. RESULTS: The study patients represented 17% of the 19,321 patients seen and discharged from the EDs over the one-week period. The most common groups of pain symptoms were abdominal pain (23%), back pain (20%), traumatic extremity pain(14%), and dental issues (12%). Patients reported an average initial pain score of 7.7 on a scale of 1 to 10. Opioids most frequently prescribed were oxycodone (52%), hydrocodone (41%), and codeine (5%); 23% of patients received more than one type of opioid. Nearly all opioids (99%) were immediate-release products, and most prescriptions (90%) were for combination thera- pies (with acetaminophen); the median number of pills was 15 per prescription. Reasons for not prescribing opioids for some patients were not explored. CONCLUSIONS: Opioid prescribing in the ED setting largely involved small numbers of pills and immediate-release formulations, in accordance with safe prescribing practices. 23 references (sgweiner@partners.org – no reprints) Copyright 2016 by Emergency Medical Abstracts – All Rights Reserved 2/16 – #21

So what’s the answer? Are doctors the source of the prescription drug problem? Yes, absolutely there are pill mills – we have just found the very tip of the iceberg in my opinion. It is just way too easy to make serious money inappropriately prescribing controlled drugs. Seems that databases should be able to find the physicians who are off the bell shaped curve. More than one standard deviation and somebody ought be taking a close look, two standard deviations, a very close look and three standard deviations – go directly to jail. The idea that physicians can prescribe tens of thousands of inappropriate prescriptions and no one blows the whistle seems hard to believe – but it’s very true.

State databases regarding controlled drugs are a great idea and long overdue. Searching these databases should be at the option of the physician and should not be mandatory. And do these databases track physician behavior as well as that of patients? If so, seems it would be easy to track the clinicians who were heavy prescribers – and certainly find the gross outliers.

And what about some CME related to appropriate pain management, particularly as it relates to chronic pain? A great idea. Frankly I recall no lectures or tutorials on how to manage chronic pain – at least in the ED. We need to learn a balanced approach – early and effective management of pain in the ED for all patients and appropriate treatment of pain (obvious or not) on an outpatient basis.

But the bottom line as it relates to the ED – we are not the problem. We don’t need any regulations or warning signs in the ED about pain management. Can we use some additional education on pain management? You bet. Education that will particularly focus on the persisting problem of oligoanalgesia in the ED and not on how to give as few Vicodin pills as humanly possible.

Write in, Be Heard:Are physicians to blame for the opioid epidemic? Do we over or under-treat pain? Let us know what you think in the comment thread below.

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